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2017 Medicare Part D Plan Formulary Information
Health Alliance Medicare HMO 40 Rx (HMO) (H1463-010-0) Benefit Details
The Health Alliance Medicare HMO 40 Rx (HMO) (H1463-010-0) Formulary Drugs Starting with the Letter V in Adams County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $74.00 Deductible: $400
Drugs Starting with Letter V Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter V Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VAGIFEM 10 MCG VAGINAL TAB	3	Preferred Brand	$47.00	N/A	None
VALACYCLOVIR 1000 MG ORAL TABLET	2*	Generic	$20.00	N/A	None
VALACYCLOVIR 500 MG ORAL TABLET	2*	Generic	$20.00	N/A	None
VALCHLOR 0.016% GEL	5	Specialty Tier	25%	N/A	P
VALCYTE FOR ORAL SOLUTION 50MG/ML	4	Non-Preferred Drug	25%	N/A	None
VALGANCICLOVIR 450 MG TABLET [Valcyte]	5	Specialty Tier	25%	N/A	None
VALGANCICLOVIR HCL 50 MG/ML [Valcyte]	4	Non-Preferred Drug	25%	N/A	None
VALPROATE SODIUM 500 mg/5 ml vl	1*	Preferred Generic	$0.00	N/A	None
Valproic 250mg/1 100 CAPSULE, LIQUID FILLED in 1 BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Valproic Acid 250mg/5mL 473 mL in 1 BOTTLE	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VALSARTAN 160 MG TABLET [Diovan]	2*	Generic	$20.00	N/A	None
VALSARTAN 320 MG TABLET [Diovan]	2*	Generic	$20.00	N/A	None
VALSARTAN 40 MG TABLET [Diovan]	2*	Generic	$20.00	N/A	None
VALSARTAN 80 MG TABLET [Diovan]	2*	Generic	$20.00	N/A	None
VALSARTAN-HCTZ 160-12.5 MG TABLET [Diovan HCT]	1*	Preferred Generic	$0.00	N/A	None
VALSARTAN-HCTZ 160-25 MG TABLET [Diovan HCT]	1*	Preferred Generic	$0.00	N/A	None
VALSARTAN-HCTZ 320-12.5 MG TABLET [Diovan HCT]	1*	Preferred Generic	$0.00	N/A	None
VALSARTAN-HCTZ 320-25 MG TABLET [Diovan HCT]	1*	Preferred Generic	$0.00	N/A	None
VALSARTAN-HCTZ 80-12.5 MG TABLET [Diovan HCT]	1*	Preferred Generic	$0.00	N/A	None
VANCOMYCIN HCL 125 MG CAPSULE	5	Specialty Tier	25%	N/A	None
VANCOMYCIN HCL 250 MG CAPSULE	5	Specialty Tier	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VANCOMYCIN HCL INJECTION 10 X 1GM VIAL (STERILE )	4	Non-Preferred Drug	25%	N/A	None
VANCOMYCIN HYDROCHLORIDE 100MG/ML 1 VIAL, PHARMACY BULK PACKAGE in 1 CASE / 95 mL in 1 VIAL, PHARMA	4	Non-Preferred Drug	25%	N/A	None
VANCOMYCIN HYDROCHLORIDE 500MG/100ML INJECTION (STERILE)	4	Non-Preferred Drug	25%	N/A	None
VANDAZOLE 0.75% GEL WITH APPLICATOR	2*	Generic	$20.00	N/A	None
VAQTA 25 UNITS/0.5 ML SYRINGE	4	Non-Preferred Drug	25%	N/A	None
VAQTA 50 UNITS/ML SYRINGE	4	Non-Preferred Drug	25%	N/A	None
Varicella-Zoster Immune Globulin 1.2 ML 104 UNT/ML Injection [Varizig]	4	Non-Preferred Drug	25%	N/A	None
VARIVAX VACCINE W/DILUENT	4	Non-Preferred Drug	25%	N/A	None
Vectibix 100mg/5mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Drug	25%	N/A	P
VELCADE 3.5MG VIAL	5	Specialty Tier	25%	N/A	P
Velivet Triphasic Regimen 3 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT per BLISTER PACK	2*	Generic	$20.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VELTASSA 16.8 GM POWDER PACKET	4	Non-Preferred Drug	25%	N/A	None
VELTASSA 25.2 GM POWDER PACKET	4	Non-Preferred Drug	25%	N/A	None
VELTASSA 8.4 GM POWDER PACKET	4	Non-Preferred Drug	25%	N/A	None
VEMLIDY 25 MG TABLET	5	Specialty Tier	25%	N/A	None
VENCLEXTA 10 MG TABLET	4	Non-Preferred Drug	25%	N/A	P
VENCLEXTA 100 MG TABLET	5	Specialty Tier	25%	N/A	P
VENCLEXTA 50 MG TABLET	4	Non-Preferred Drug	25%	N/A	P
VENCLEXTA STARTING PACK	5	Specialty Tier	25%	N/A	P
VENLAFAXINE HCL 100MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HCL 25MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HCL 37.5MG TABLET	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VENLAFAXINE HCL 50MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HCL 75MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HYDROCHLORIDE 150MG CAPSULES EXTENDED RELEASE	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HYDROCHLORIDE 37.5MG CAPSULES EXTENDED RELEASE	1*	Preferred Generic	$0.00	N/A	None
VENLAFAXINE HYDROCHLORIDE 75MG CAPSULES EXTENDED RELEASE	1*	Preferred Generic	$0.00	N/A	None
Ventavis 0.01mg/mL	5	Specialty Tier	25%	N/A	P
Ventavis 0.02mg/mL	5	Specialty Tier	25%	N/A	P
VENTOLIN HFA 90MCG INHALER	3	Preferred Brand	$47.00	N/A	None
VERAPAMIL 120MG CAP PELLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL 180MG CAP PELLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL 2.5MG/ML AMPUL	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VERAPAMIL 240MG CAP PELLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL 40MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL ER 100MG CAPSULE 24HR SR PELLETS	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL ER 120 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL ER 180 MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL ER 200MG CAPSULE 24HR SR PELLETS (100 CT)	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL ER 300MG CAPSULE 24HR SR PELLETS	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL HCL 120MG TABLET	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL HCL 360MG CAPSULES SUSTAINED RELEASE	1*	Preferred Generic	$0.00	N/A	None
VERAPAMIL HCL 80MG TABLET	1*	Preferred Generic	$0.00	N/A	None
Verapamil Hydrochloride 240mg/1 500 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC	1*	Preferred Generic	$0.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VEREGEN 15% OINTMENT	5	Specialty Tier	25%	N/A	None
VERSACLOZ 50 MG/ML SUSPENSION	4	Non-Preferred Drug	25%	N/A	None
VESICARE 10MG TABLET	3	Preferred Brand	$47.00	N/A	None
VESICARE 5MG TABLET (90 CT)	3	Preferred Brand	$47.00	N/A	None
Vestura 3 mg-0.02 mg tablet	2*	Generic	$20.00	N/A	None
VIBRAMYCIN 50MG/5ML SYRUP	4	Non-Preferred Drug	25%	N/A	None
VICODIN 5-300 MG TABLET	2*	Generic	$20.00	N/A	Q:240 /30Days
VICODIN ES 7.5-300 MG TABLET	2*	Generic	$20.00	N/A	Q:240 /30Days
VICODIN HP 10-300 MG TABLET	2*	Generic	$20.00	N/A	Q:240 /30Days
VICTOZA 3-PAK 18 MG/3 ML PEN	4	Non-Preferred Drug	25%	N/A	S
VIDEX 2GM PEDIATRIC TUBEX	4	Non-Preferred Drug	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIENVA-28 TABLET	2*	Generic	$20.00	N/A	None
VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL]	5	Specialty Tier	25%	N/A	P
VIGABATRIN 500 MG ORAL TABLET [SABRIL]	5	Specialty Tier	25%	N/A	P
VIGAMOX 0.5% EYE DROPS	4	Non-Preferred Drug	25%	N/A	None
VIIBRYD 10-20 MG STARTER PACK	4	Non-Preferred Drug	25%	N/A	S Q:60 /365Days
VIIBRYD 10mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	25%	N/A	S Q:30 /30Days
VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	25%	N/A	S Q:30 /30Days
VIIBRYD 40mg/1 30 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Drug	25%	N/A	S Q:30 /30Days
VIMPAT 10 MG/ML SOLUTION	3	Preferred Brand	$47.00	N/A	None
Vimpat 100mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$47.00	N/A	None
Vimpat 10mg/mL 10 VIAL, GLASS per CARTON / 20 mL in 1 VIAL, GLASS	3	Preferred Brand	$47.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Vimpat 150mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$47.00	N/A	None
Vimpat 200mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$47.00	N/A	None
Vimpat 50mg/1 60 FILM COATED TABLETS in BOTTLE, PLASTIC	3	Preferred Brand	$47.00	N/A	None
VINBLASTINE 1 MG/ML VIAL	1*	Preferred Generic	$0.00	N/A	P
VINCRISTINE 1MG/ML VIAL	1*	Preferred Generic	$0.00	N/A	P
VINCRISTINE 1MG/ML VIAL	1*	Preferred Generic	$0.00	N/A	P
VINORELBINE 10MG/ML VIAL 5ML VIAL	1*	Preferred Generic	$0.00	N/A	None
VIRACEPT 250MG TABLET	5	Specialty Tier	25%	N/A	None
VIRACEPT 625MG TABLET	5	Specialty Tier	25%	N/A	None
VIREAD 150 MG TABLET	4	Non-Preferred Drug	25%	N/A	None
VIREAD 200 MG TABLET	4	Non-Preferred Drug	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VIREAD 250 MG TABLET	4	Non-Preferred Drug	25%	N/A	None
VIREAD 300MG TABLET	5	Specialty Tier	25%	N/A	None
VIREAD POWDER	4	Non-Preferred Drug	25%	N/A	None
VIVITROL INJECTABLE SUSPENSION 380MG/VIAL	5	Specialty Tier	25%	N/A	None
VORICONAZOLE 200 MG VIAL	2*	Generic	$20.00	N/A	P
Voriconazole 200mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	25%	N/A	P
Voriconazole 40 mg/ml susp	5	Specialty Tier	25%	N/A	P
Voriconazole 50mg/1 30 FILM COATED TABLETS in BOTTLE, PLASTIC	5	Specialty Tier	25%	N/A	P
VOTRIENT 200 MG TABLET	5	Specialty Tier	25%	N/A	P
VPRIV INJECTION SOLUTION 2.5 MG/ML	5	Specialty Tier	25%	N/A	P
VRAYLAR 1.5 MG CAP	5	Specialty Tier	25%	N/A	S Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
VRAYLAR 1.5 MG-3 MG PACK	4	Non-Preferred Drug	25%	N/A	S Q:14 /365Days
VRAYLAR 3 MG CAP	5	Specialty Tier	25%	N/A	S Q:30 /30Days
VRAYLAR 4.5 MG CAP	5	Specialty Tier	25%	N/A	S Q:30 /30Days
VRAYLAR 6 MG CAP	5	Specialty Tier	25%	N/A	S Q:30 /30Days
Vyfemla 28 tablet	2*	Generic	$20.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Health Alliance Medicare HMO 40 Rx (HMO) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $400 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2017 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.